Podcast
Questions and Answers
Which action would the nurse undertake first when beginning to formulate a patient's plan of care?
Which action would the nurse undertake first when beginning to formulate a patient's plan of care?
- Identify realistic outcome indicators
- Rank patient concerns from assessment data (correct)
- List possible treatment options
- Consult with health care team members
Which resource is most helpful when prioritizing identified nursing diagnoses?
Which resource is most helpful when prioritizing identified nursing diagnoses?
- Maslow's hierarchy of needs (correct)
- Nursing Outcomes Classification (NOC)
- Gordon's functional health patterns
- Nursing Interventions Classification (NIC)
If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care?
If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first while planning care?
- Knowledge Deficit
- Acute Pain (correct)
- Fatigue
- Body Image Disturbance
Which statement illustrates a characteristic of goals within the care planning process?
Which statement illustrates a characteristic of goals within the care planning process?
If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.)
If the nurse chooses the Nursing Outcome Classification (NOC), Appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.)
Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult?
Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult?
Which intervention can the nurse initiate independently while providing patient care? (Select all that apply.)
Which intervention can the nurse initiate independently while providing patient care? (Select all that apply.)
The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider?
The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider?
Which situation indicates the greatest need for collaborative interventions provided by several health care team members?
Which situation indicates the greatest need for collaborative interventions provided by several health care team members?
The Nursing Interventions Classification (NIC) index is used for what purpose in the planning step?
The Nursing Interventions Classification (NIC) index is used for what purpose in the planning step?
The Nursing Outcomes Classification (NOC) is used for what purpose in the planning step?
The Nursing Outcomes Classification (NOC) is used for what purpose in the planning step?
Prioritization of nursing diagnoses requires the use of which of the following tools?
Prioritization of nursing diagnoses requires the use of which of the following tools?
Inclusion of the patient in the planning process is significant due to the fact that
Inclusion of the patient in the planning process is significant due to the fact that
The charge nurse of a cardiac unit running code situation is practicing what type of planning?
The charge nurse of a cardiac unit running code situation is practicing what type of planning?
The nurse working in the patient discharge center is practicing what type of planning?
The nurse working in the patient discharge center is practicing what type of planning?
Identify physician-initiated interventions:
Identify physician-initiated interventions:
The nurse has provided home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement by the mother indicates a need for further instruction?
The nurse has provided home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement by the mother indicates a need for further instruction?
Outcome indicators are
Outcome indicators are
Goals are set during the planning step and (Select all that apply.)
Goals are set during the planning step and (Select all that apply.)
Standards of care guide practice through (Select all that apply.)
Standards of care guide practice through (Select all that apply.)
Identify nurse-initiated interventions: (Select all that apply.)
Identify nurse-initiated interventions: (Select all that apply.)
Identify the situation where collaborative interventions could be implemented: (Select all that apply.)
Identify the situation where collaborative interventions could be implemented: (Select all that apply.)
What should the nurse consider before implementation of all nursing interventions? (Select all that apply.)
What should the nurse consider before implementation of all nursing interventions? (Select all that apply.)
The nurse facilitates the use of the intellectual standard of critical thinking of significance by posing which question to determine the patient's understanding of his or her new diagnosis of type 1 diabetes mellitus on his or her lifestyle?
The nurse facilitates the use of the intellectual standard of critical thinking of significance by posing which question to determine the patient's understanding of his or her new diagnosis of type 1 diabetes mellitus on his or her lifestyle?
In providing care to a newly admitted patient, the nurse's inferences are more accurate if based upon which of the following?
In providing care to a newly admitted patient, the nurse's inferences are more accurate if based upon which of the following?
During the postoperative assessment on a patient, the nurse has a 'hunch' that the patient has a postoperative complication based upon?
During the postoperative assessment on a patient, the nurse has a 'hunch' that the patient has a postoperative complication based upon?
In using intuition to address a clinical problem, the expert nurse bases his or her approach upon which of the following?
In using intuition to address a clinical problem, the expert nurse bases his or her approach upon which of the following?
A new graduate nurse explains a new approach in the positioning of patients with chronic low back pain. The nurse preceptor responds, 'That is not the way we do it here.' The preceptor's response illustrates which error in critical thinking?
A new graduate nurse explains a new approach in the positioning of patients with chronic low back pain. The nurse preceptor responds, 'That is not the way we do it here.' The preceptor's response illustrates which error in critical thinking?
In preparing to administer medications to a patient, the nurse notes a medication that she has never administered. If the nurse administers the medication without researching the medication, this represents which error in critical thinking?
In preparing to administer medications to a patient, the nurse notes a medication that she has never administered. If the nurse administers the medication without researching the medication, this represents which error in critical thinking?
In preparing for a certification examination, the nurse chooses to develop a concept map to help understand the content. This strategy is based upon which characteristics of concept maps? (Select all that apply.)
In preparing for a certification examination, the nurse chooses to develop a concept map to help understand the content. This strategy is based upon which characteristics of concept maps? (Select all that apply.)
What term best describes the nature of the nursing process?
What term best describes the nature of the nursing process?
A disoriented patient is admitted to the hospital accompanied by his spouse. From whom should the nurse collect subjective data on this patient?
A disoriented patient is admitted to the hospital accompanied by his spouse. From whom should the nurse collect subjective data on this patient?
Prior to identifying accurate nursing diagnoses, what action must be taken by the nurse?
Prior to identifying accurate nursing diagnoses, what action must be taken by the nurse?
A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse's first action?
A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse's first action?
Which statement is a correctly written example of an actual nursing diagnosis?
Which statement is a correctly written example of an actual nursing diagnosis?
Which long-term goal is written correctly?
Which long-term goal is written correctly?
What phrase best describes the essence of critical thinking?
What phrase best describes the essence of critical thinking?
Which body is responsible for defining and disseminating information on nursing diagnoses?
Which body is responsible for defining and disseminating information on nursing diagnoses?
The statement 'ongoing collection of data' best describes which phase of the nursing process?
The statement 'ongoing collection of data' best describes which phase of the nursing process?
Which statement illustrates the most measurable outcome indicator?
Which statement illustrates the most measurable outcome indicator?
What should be the focus of all nursing interventions?
What should be the focus of all nursing interventions?
Which action should the nurse take 30 minutes after administering oral pain medication to a patient?
Which action should the nurse take 30 minutes after administering oral pain medication to a patient?
Which piece of assessment data may be accurately obtained during the observation phase?
Which piece of assessment data may be accurately obtained during the observation phase?
Patients from which generation would be most comfortable with the nurse using electronic resources for health screening?
Patients from which generation would be most comfortable with the nurse using electronic resources for health screening?
Which type of question would be best for the nurse to use when trying to determine the extent of a patient's knowledge concerning a disease process?
Which type of question would be best for the nurse to use when trying to determine the extent of a patient's knowledge concerning a disease process?
Which statement by the nurse best describes health history assessment?
Which statement by the nurse best describes health history assessment?
Which statement illustrates appropriate documentation following palpation?
Which statement illustrates appropriate documentation following palpation?
What type of assessment is most appropriate for a patient newly admitted to the hospital for intermittent loss of vision in the left eye?
What type of assessment is most appropriate for a patient newly admitted to the hospital for intermittent loss of vision in the left eye?
Which statement is the best example of subjective, secondary data?
Which statement is the best example of subjective, secondary data?
A patient is admitted to the nursing unit with numbness and tingling in the right hand, pain in the cervical spine, and occasional loss of consciousness. Into which functional health pattern would the nurse organize this data?
A patient is admitted to the nursing unit with numbness and tingling in the right hand, pain in the cervical spine, and occasional loss of consciousness. Into which functional health pattern would the nurse organize this data?
Which information gathered during assessment is considered to be subjective data?
Which information gathered during assessment is considered to be subjective data?
The most important source in data collection is/are?
The most important source in data collection is/are?
Which action(s) should the nurse take during the termination phase of the patient interview? (Select all that apply.)
Which action(s) should the nurse take during the termination phase of the patient interview? (Select all that apply.)
What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I?
What is the most important reason for nurses to use a standardized taxonomy such as NANDA-I?
Which nursing diagnosis is appropriately written? (Select all that apply.)
Which nursing diagnosis is appropriately written? (Select all that apply.)
Which phrase best represents a related factor in an actual nursing diagnosis?
Which phrase best represents a related factor in an actual nursing diagnosis?
Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.)
Which action does the nurse need to take before determining the type(s) of nursing diagnoses that are applicable to a patient? (Select all that apply.)
What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis?
What is the primary difference between a risk nursing diagnosis and an actual nursing diagnosis?
What is the most important action for a nurse to take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy?
What is the most important action for a nurse to take in order to have a new nursing diagnosis considered for inclusion in the NANDA-I taxonomy?
What is the most significant problem that may result from improperly written nursing diagnostic statements?
What is the most significant problem that may result from improperly written nursing diagnostic statements?
Which statement best describes the relationship of medical diagnoses and nursing diagnoses?
Which statement best describes the relationship of medical diagnoses and nursing diagnoses?
A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take?
A patient has just experienced a cardiac arrest on the unit. The nurse has implemented the acute care plan for management of code situations. What is the next step the nurse should take?
What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.)
What signs and symptoms would the nurse appropriately cluster for a patient with extreme anxiety? (Select all that apply.)
The hospice nurse believes the nursing diagnosis chronic sorrow is significant in the recovery process of patients recently experiencing a loss. What is required to support the addition of new nursing diagnoses to the NANDA-I taxonomy?
The hospice nurse believes the nursing diagnosis chronic sorrow is significant in the recovery process of patients recently experiencing a loss. What is required to support the addition of new nursing diagnoses to the NANDA-I taxonomy?
The nurse has just received a postoperative patient to the floor post-ureteral stone manipulation. Choose the priority nursing diagnosis.
The nurse has just received a postoperative patient to the floor post-ureteral stone manipulation. Choose the priority nursing diagnosis.
The relationship of the medical diagnosis to the nursing diagnosis is?
The relationship of the medical diagnosis to the nursing diagnosis is?
An example of implementation of evidence-based practice by the nurse would be the nurse?
An example of implementation of evidence-based practice by the nurse would be the nurse?
The clustering of data is significant to the nursing diagnoses step because clustering of data will?
The clustering of data is significant to the nursing diagnoses step because clustering of data will?
Study Notes
Clinical Judgement and Nursing Process
- Critical thinking involves assessing the impact of medical diagnoses on nursing actions.
- Accurate nursing inferences are primarily based on objective data.
- Intuition in nursing aids in recognizing complications during assessments.
Nursing Diagnoses
- Identifying related factors enhances understanding of nursing diagnoses.
- Nursing diagnoses must be correctly written to guide effective patient care planning.
- Differentiating between actual nursing diagnoses and risk diagnoses is crucial for appropriate interventions.
Patient Assessment
- Ongoing data collection is essential and is part of the assessment phase.
- Subjective data often comes directly from patient reports of symptoms or experiences.
- Health assessments should be thorough, systematic, and continuous throughout patient interactions.
Goals and Outcomes
- Clear, measurable goals are necessary to evaluate patient progress effectively.
- Both long-term and short-term goals should be specific and time-bound.
- Active participation and expressions of desire from patients suggest engagement in their care process.
Effective Communication
- During patient interviews, open-ended questions yield more comprehensive patient insights.
- Validating and summarizing information received enhances the clarity and accuracy of data collected.
Importance of Evidence-Based Practice
- Implementing evidence-based protocols ensures patient safety and enhances care quality.
- The nursing process requires collaboration with a healthcare team to develop comprehensive care plans based on assessment findings.
Prioritization in Nursing Care
- Acute and severe symptoms, such as pain, should take precedence in care planning.
- Use of resources like Maslow's hierarchy can facilitate sound prioritization of nursing diagnoses.
Documentation Standards
- Documentation must be clear and accurate to reflect observations and patient interactions properly.
- Utilizing standardized nursing terminology is essential to maintain clarity and consistency in nursing practice.
Challenges in Nursing Judgment
- Errors in critical thinking can arise from biases, lack of information, or illogical assumptions.
- Continuous education and awareness of personal biases improve critical thinking in nursing practice.
Models and Classification Systems
- Nursing interventions and outcomes are standardized using specific classification systems (NIC, NOC).
- Familiarity with these systems aids in the identification and evaluation of nursing actions and patient responses.### Patient-Centered Care
- Crucial to listen to a patient's concerns and beliefs when developing a care plan.
- Collaborating with social workers can help identify resources for patient support.
- Involving family and friends enhances the care process and provides a broader support network.
- Providing written care options aids in informed decision-making for patients and families.
Independent Nursing Interventions
- Nurses can independently auscultate lung sounds, monitor skin integrity, and apply heel protectors.
- Ordering blood transfusions and adjusting antibiotic dosages require physician orders.
Dependent Nursing Actions
- Administering oxygen requires an order from a primary care provider.
- Assessing oxygen saturation and evaluating peripheral circulation are independent actions.
Collaborative Interventions
- Hospice referrals signify the need for collaborative care from various health care professionals.
- Teamwork is essential for complex patient needs.
Nursing Intervention Classifications
- NIC index guides nursing interventions selection based on specific diagnoses.
- Regular updates ensure the accuracy of nursing interventions listed in NIC.
Nursing Outcomes Classification
- NOC provides standardized indicators for assessing nursing-sensitive outcomes.
- Useful in determining the appropriateness of goals for implementation.
Prioritization Tools
- Maslow's Hierarchy of Needs assists in prioritizing nursing diagnoses based on patient needs.
- The ABCs (airway, breathing, circulation) are fundamental in assessing and prioritizing care.
Patient Inclusion in Planning
- Involving patients in planning increases the likelihood of achieving health goals.
- Patient-driven goal setting is essential for effective care.
Types of Nursing Planning
- Acute planning focuses on immediate patient needs, especially during critical situations.
- Discharge planning prepares patients for post-hospitalization care and recovery.
Physician-Initiated vs. Nurse-Initiated Interventions
- Administering antibiotics is a physician-initiated intervention.
- Nurse-initiated interventions can include preadmission teaching and modifying care plans based on assessments.
Home Care Instructions
- Parents need thorough understanding to ensure proper post-operative care for children.
- Statements indicating misunderstanding of discharge instructions necessitate further education.
Outcome Indicators
- Measurable criteria that evaluate whether goals set during the planning phase were achieved.
- Broader statements reflect nursing diagnoses and inform practice quality.
Goals in Nursing Care
- Goals are broad statements outlining the aims of nursing care and can be both short-term and long-term.
- Clearly defined, realistic, and measurable goals foster effective nursing practice.
Standards of Care
- Standards direct nursing practice through prudes and accountability.
- They help in creating comprehensive patient care plans.
Nurse-Initiated Interventions
- Ordering protective devices and conducting education sessions are within the nurse's scope of practice.
- Collaborating with social workers enriches the patient's support systems.
Situations for Collaborative Interventions
- Implementing interventions for physical therapy, home health care, and palliative care require collaboration.
- Surgical procedures typically involve a distinct set of professionals and are less about collaboration.
Considerations Before Nursing Interventions
- Address potential communication barriers and cultural practices to ensure effective care.
- Understanding the scope of nursing practice is essential before implementing interventions.
- Assessing the patient’s functional status is crucial for tailored care.
Studying That Suits You
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Description
Prepare for your Clinical Judgement Test with this quiz covering Chapters 4-9 and 20 from the Yoost textbook. Each question is designed to reinforce your understanding and readiness for the exam. Flashcards will help you recall essential definitions and concepts.
